Provider Demographics
NPI:1760745871
Name:IRVINE, DANIELLE J (OD)
Entity Type:Individual
Prefix:DR
First Name:DANIELLE
Middle Name:J
Last Name:IRVINE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1323 E COLORADO ST APT 4
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53207-2271
Mailing Address - Country:US
Mailing Address - Phone:262-689-1629
Mailing Address - Fax:
Practice Address - Street 1:309 N FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:WI
Practice Address - Zip Code:53074-1905
Practice Address - Country:US
Practice Address - Phone:262-261-5252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-22
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010557152W00000X, 152WL0500X
WI3589-35152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL502720065OtherMEDICARE PTAN
IL046010557Medicaid